Bayshire Torrey Pines Post-Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to implement policies and procedures when the facility failed to conduct a comprehensive investigation of allegations of inappropriate comments that involved one resident (Resident 1). This failure had the potential for allegations of inappropriate behavior to not be fully investigated. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included visual loss and need for assistance with personal care. According to the Minimum Data Set (MDS, an assessment tool), Resident 1 was cognitively intact with a BIMS (Brief Interview of Mental Status, a cognition tool) score of 12. On 10/22/24 at 10:59 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated on 9/16/24 Certified Nursing Assistant (CNA) 1 reported while assisting Resident 1 with a shower, Resident 1 made inappropriate comments to her. The DSD stated the comments were of a sexual nature. On 10/22/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents received foods in measured amounts when standardized recipes were not followed for residents receiving pureed diets. This failure had the potential for residents to have decreased nutrition and possible weight loss. Findings: An observation of the pureed food production for lunch was conducted on 1/10/24 at 10:30 A.M. The Culinary Director (CD) cut seven portions of the ravioli bake casserole and placed them in the blender. The CD did not measure or weigh the portions. In addition, seven portions of cauliflower were pureed with no measurement or weighing of the portions. The CD poured chicken stock into the blender without measuring the amount. There was no recipe/recipe book available for the CD to use. An interview was conducted with the CD on 1/10/24 at 10:45 A.M. The CD stated, I did not use a recipe, I know them. There is a recipe binder here in the department. It is important to follow the recipes to keep nutritional value. An interview was conducted with the Dietary Services Manager…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food safety was maintained in the kitchen according to facility policy when multiple food items were not dated or were dated in the future; and no received on or use by date was noted. These deficient practices had the potential to cause foodborne illness. Findings: An observation of the facility's kitchen was conducted on 1/8/24 at 8:30 A.M. Seven containers had no received or expire dates: parsley flakes, black pepper, granulated garlic, oregano, paprika, thyme leaves, and basil. Multiple items were marked with received dates which were in the future (2/5/24): a one-pound package of ground beef, a one-pound package of ground pork, boxes of [NAME] Krispy Treats, quick oats, boxed pancake mix, boxed cake mix, cans of tomato soup, cans of cranberry sauce, cans of corned beef hash and a box of quinoa. There were multiple items with dates but not identified as whether the date was received by, or use-by dates: pecan pieces, sugar, pancake syrup, coffee creamer, brown sugar, salt, pound cake, and frozen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to treat a resident with dignity when a Certified Nursing Assistant (CNA 1) stood while assisting with breakfast (Resident 108). This failure had the potential to cause Resident 108 a loss of self-esteem and/or self-worth. Findings: Resident 108 was admitted to the facility on [DATE] with diagnoses to include generalized muscle weakness and dysphagia (difficulty swallowing), per the admission Record. On 12/29/23, Resident 108 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On the same date, Resident 108 was assessed to require partial to moderate assistance with eating. On 1/9/24 at 8:30 A.M., an observation was conducted in the dining room. Six residents were seated, five were feeding themselves. Resident 108 was seated at a table, with his hands in his lap. CNA 1 was standing on Resident 108's right side, feeding him the plated food. On 1/9/24 at 8:35 A.M., an interview was conducted…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to develop and transmit Discharge Minimum Data Set (MDS, a comprehensive assessment and care screening tool) assessments for two of two residents reviewed for Resident Assessment (Residents 5, 8). This failure resulted in Resident 5 and 8's discharge status not being communicated to the Centers for Medicare and Medicaid (CMS) as required, and had the potential to result in delayed quality measurements from the data. Findings: On 1/11/24, a record review was conducted. Per the MDS 3.0 Resident Assessments list: Resident 5 was due for a Discharge MDS assessment on 9/19/23. Resident 5's MDS status was indicated as, In progress. Resident 8 was due for a Discharge MDS assessment on 8/28/23. Resident 8's MDS status was indicated as, In progress. On 1/11/24 at 2:35 P.M., a concurrent interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated it was important to complete a Discharge MDS when a resident left the facility. The MDSC reviewed Resident 5 and Resident 8's MDS summaries and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to utilize urine collection containers (UCC) in a safe, clean manner for two of two residents reviewed for Environment of Care. This failure had the potential to cause urinary tract infections (UTIs). Findings: 1. Resident 156 was admitted to the facility on [DATE] with diagnosis to include a fractured bone in the spine and UTI, per the admission Record. On 1/8/24, at 9:30 A.M., Resident 156 was observed in bed. A plastic device with long tubing was observed set on towels on the floor. The coiled tubing went from the device on the floor up under the blankets and between Resident 156's legs. A liquid which appeared to be urine was in the tubing, and in the UCC. Resident 156 stated she did not know what the tubing or device were for. On 1/11/24, a record review was conducted. On 12/29/23, Resident 156 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. Per a nursing admission Evaluation, dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the acceptable standard of care for the blood pressure medication was followed for one of two sampled residents. This failure had the potential to affect Client 1 ' s quality of life, health and well- being. Findings: Resident 1 was admitted to the facility on [DATE], per the facility ' s Face Sheet. On 11/15/23 a record review was conducted. Resident 1 had diagnoses which included subarachnoid bleed (bleeding in the space that surrounds the brain), per the physician ' s admission history and physical visit, dated 10/6/23. Per the MDS, dated [DATE], Resident 1 had a BIMS of 11 (BIM score of 8-12 indicated a resident was moderately cognitively impaired). On 11/15/23 at 3:07 P.M., an interview and record review were conducted with Licensed Nurse (LN) 2. The LN 2 stated Client 1 had an order of blood pressure medicine since she was admitted to the facility on [DATE]. The blood pressure medication was ordered one time a day and scheduled at 9 A.M.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide regular showers to two of two sampled residents (1, 2). As a result, Resident 1 and Resident 2 were placed at an increased risk of skin infections. Findings: 1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include paraplegia (difficulty moving the lower half of the body) and muscle weakness. Per the facility's Shower Schedule, each resident had showers scheduled on two days of the week based on what room they were in. Per the facility's Body Check Sheets, there was documentation of the facility providing 7 of the 11 scheduled showers to Resident 1. There was no documentation of the facility offering a shower to Resident 1 on 8/3, 8/10, 8/14, or 9/1. On 10/27/23 at 11:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated, she was not able to find documentation to explain the missing shower notes for Resident 2. The DON further stated, the staff should…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the kitchen staff competently carried out the functions of the food and nutrition services department when: 1. A [NAME] (CK 1) and two diet aides (DA) 1 and DA 2 did not use standardized recipes and therapeutic menus in the kitchen to prepare and plate resident meals. 2. A [NAME] (CK 2) and a diet aide (DA 3) did not use a therapeutic menu or guide to prepare pureed meals and thickened drinks. 3. A [NAME] (CK 4) did not obtain or document the final cooking temperatures of prepared food for two months. 4. A Diet Aide (DA 2) did not correctly plate meals for residents on therapeutically prescribed carbohydrate-controlled (CCHO) diets. 5. A [NAME] (CK 3) did not know how to calibrate a food thermometer. 6. CK 3 who also worked as a dishwasher, did not know how to test a high-temperature dish machine to ensure it was operating within the specified heat range according to manufacturer's guidelines. 7. A [NAME] (CK 4) did not use proper…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews the facility failed to ensure the use of standardized recipes and therapeutic menus approved by a Registered Dietitian were used for skilled nursing home residents on therapeutic diets. This practice led to residents receiving meals did not match their physician ordered diet, or medical condition, which had the potential to compromise their nutrition status and other health consequences such as choking or death. Cross references: F800, F801, F804, F809 Findings: During an interview on 2/27/23 at 8:46 AM with CK 1 in the main kitchen, CK 1 stated he was the main cook in the mornings that prepares breakfast and lunch meals for the facility's residents, including the skilled nursing facility (SNF). CK 1 stated this morning he prepared 2 pureed (i.e. foods blended to a thick mashed potato texture for patients with difficulty swallowing), 5 mechanical soft (i.e. foods blended to a smaller pieces for ease in chewing and swallowing), 6 ground (i.e. food blended to a softer chewable texture for patients with difficulty chewing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents received foods that retained nutritive value and were served at an appetizing temperature when: 1. Standardized recipes and therapeutic menus were not followed for residents receiving pureed diets. 2. Holding temperatures on the tray line and resident test tray were below acceptable range and three residents complained of cold food. This failure had the potential to result in decreased intake and further compromise the nutritional status of 38 residents receiving therapeutic diets from the facility's kitchens. 1. During an observation and interview in the main kitchen on 2/27/23 at 3:36 PM, CK 2 was preparing shredded barbeque chicken for pureed resident meals. CK 2 placed 3 scoops of shredded chicken in the blender and then added water directly from the faucet into the blender and blended the chicken before it was poured into a small silver shot pan, covered, and placed on the warming tray. CK 2 stated she did not always use thickener but when she did, she would just eyeball the amount of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a meal span of less than fourteen (14) hours between a substantial evening meal and breakfast the following day. This failure had the potential to increase hunger and negatively affect the nutrition status of 38 residents who consume meals at the Skilled Nursing facility. Cross reference F800, F804 Findings: A record review of the facilities scheduled mealtimes provided by EC on 2/27/28 indicated, breakfast was served at 7:30 A.M., Lunch was served at 11:15 A.M. and dinner was served at 4:15 P.M. On 2/27/23 at 4:45 P.M., an observation of the SNF satellite kitchen dining room was conducted. The SNF dining room did not have a main menu posted for the day, week, or month for the residents. DA 2 confirmed there were no menus posted in the SNF dining room. During an observation on 2/28/23 at 7:40 A.M., the satellite dining room did not have any meal carts being loaded. During an observation on 2/28/23 at 8:00 A.M., no meal carts were observed being delivered. During an observation and interview on 2/28/23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were maintained in the kitchen according to standards of practice and facility policy when: 1. A white powdered substance was stored in the main kitchen unlabeled and undated in a large plastic bin. 2. Breadcrumbs were opened and undated with no cover or closure device. 3. The walk-in refrigerator and satellite kitchen refrigerator had multiple TCS (time/temperature control for food safety foods- meats, dairy, pasta, etc.) foods that were stored uncovered, unlabeled, and/or undated. 4. The temperature of milk stored in the satellite kitchen refrigerator was 44.8F when tested. 5. A dirty rag with brown stains was on tray with nine 8 oz. glasses of juice on it in the satellite kitchen reach-in refrigerator. 6. The dish machine sanitizer solution in the satellite kitchen was not maintained at the correct concentration; the chemical sanitizer testing strip indicated there was no sanitizer solution entering the dish machine during the wash cycle. 7. Eighteen expired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a kitchen garbage bin was kept clean and free of debris. This failure had the potential to promote an unsanitary environment that harbors pests and expose to unsafe conditions. Cross reference F800, F802, 812 Findings: During the initial tour of the main kitchen on 2/27/23 at 8:26 A.M., an observation was conducted. The main kitchen was cluttered and with multiple empty cardboard boxes, empty food containers, chemical bottles scattered on the floor, along with wrappers, trash and other debris on the floor along the walkway from the kitchen entrance to the food equipment area. During an observation and interview on 3/6/23 at 12:39 P.M., CK 4 was observed taking the kitchen trash bin outside to empty the contents in the dumpster. An observation of the inside of the kitchen trash bin was conducted and the bin was dirty with old food and debris. CK 4 brought the kitchen trash bin back inside without cleaning or washing out the old food waste. CK 4 placed a new trash bag in the bin; which was observed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and document review, the facility failed to ensure two ice machines and the skilled nursing facility (SNF) kitchen dish machine were maintained in a safe, operating, and fully functioning manner, according to the manufacturer's guidelines and standards of practice. These failures had the potential to expose 38 residents to unsafe, unsanitary ice, which could lead to foodborne illnesses and further compromise their health. Cross reference F800, F801, F802, F812 Findings: 1. SNF Satellite and Main kitchen Dish machines On 2/27/23 at 10:06 AM, a concurrent observation and interview was conducted with DA 1 in the satellite kitchen. DA 1 demonstrated how the low temperature dishwasher operated for the wash and rinse cycles. DA 1 showed how to check the chemical chlorine sanitizer with the manufacturer's test strips. DA 1 dipped a test strip from the first set of strips inside the dish machine solution and it was white, without a color change. DA 1 tried a different set of test strips, and there was no color change, and the container indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure when: 1. Nursing staff were competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice and administration of nebulizer treatment (a liquid medicaine to help control breathing problems). Four out of Four nursing staff in three out of three nursing stations, did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers. 2. In addition, the facility failed to provide comprehensive nursing services for two of 39 sampled residents (25, 549) when Resident 25 medications were not ordered. 3. The director of Staff Development (DSD) did not review and ensure registry certified nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure a system of receipt and disposition of Controlled Substances (CS- a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) were established and implemented when: 1. The facility did not have a system in place in sufficient detail to accurately reconcile disposition of all controlled drugs. 2. The facility did not have a system in place to accurately periodically reconcile controlled drugs and account for controlled drugs for two out of two sampled residents (Residents 20, 555). These failures increased the risk for loss and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of a Controlled Substance. Findings: 1. During a concurrent observation and interview on 2/27/23, at 11:23 a.m., with Interim Director of Nursing (IDON) 1 in the medication room, discontinued CS medication were observed locked in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to ensure four of four sampled residents (Residents 547, 245, 3, 25) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 547 was administered clonazepam (medication that works in brain to help with anxiety) without an appropriate end date. 2. Resident 245 was administered alprazolam, no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of alprazolam. 3. Resident 3 was administered trazodone (medication for depression) without appropriate clinical justification for dose increase and no resident specific behavioral interventions were attempted or implemented prior to initiation and/or during use of trazodone. 4. Resident 25 was administered sertraline (medication for depression) without appropriate clinical justification for dose increase, gradual dose reduction, and no resident specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) addressed the dietary aides' training and competencies in order to provide food and nutrition services in a competent and safe manner. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801) Findings: On 2/28/23 at 5:31 P.M., an immediate jeopardy was called due to the lack of oversight of dietetic and food services by a full-time dietetic services supervisor manager, which resulted in kitchen staff not having adequate training, skills, and tools to carry out the Food and Nutrition Services in a competent and safe manner. A document review of the facility's Facility Assessment, updated on 3/7/23, was conducted. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility Medical Director failed to ensure dietary policies and procedures and the Facility Assessment (process used by facilities to assess the needs of its resident population and required resources to provide the care and services the residents need) policy were implemented, when dietary staff did not prepare the residents' meals in accordance with the physician's orders. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801 and F-838) Findings: On 2/28/23 at 5:31 P.M., an immediate jeopardy was called due to the lack of oversight of dietetic and food services by a full-time dietetic services supervisor manager, which resulted in kitchen staff not having adequate training, skills, and tools to carry out the Food and Nutrition Services in a competent and safe manner. An interview with the Medical Director (MD) was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI - a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining, and improving safety and quality in nursing homes) did not identify areas of improvement in the facility's dietary services, when dietary staff did not prepare the residents' meals in accordance with the physician's orders. In addition, the facility's QAPI program policy and procedure did not clearly describe all the elements required in accordance to the federal regulation. This failure placed 38 of the 38 residents in the facility, who received food from the licensed kitchen, at risk for food-borne illness, (illness caused by food contaminated with bacteria, viruses, or toxins) and not meeting the nutritional needs of the residents. (Refer to F-801) In addition, an unclear QAPI policy and procedure had the potential to affect the facility's ability to efficiently identify high-risk (refers to care or service areas associated with significant risk to the health or safety of residents),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 9. During a staff interview on 2/27/23 at approximately 8:20 am, IDON 1 (Interim Director of Nursing) identified the quarantine/isolation area as the three rooms at the end of the first hallway. IDON1 stated the Red Zone (isolation area) had COVID precautions in place for the residents with COVID 19 (dangerous viral infection) diagnoses. During observation on 2/27/23 at 9:09 am, the first hallway was observed to have a Red Zone laminated sheet attached to a post in front of the two Northeast (NE) rooms. In addition, three partially filled isolation carts, along with instruction sheets for donning Personal Protection Equipment (PPE), that included gowns, gloves, and mask, were observed outside of Resident 348, 349, and 350's rooms. Red Zone signs observed outside of Resident's 348 and 349's rooms. An observation and record review were conducted on 2/27/23 of the medical charts for Residents 346, 347, 348, 349, and 350. A. Resident 348's, diagnoses included a COVID positive infection and an exposure to Candida…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a qualified Infection Preventionist (IP- a person who coordinated the handling of facility's infection control practices) was employed full time. As a result, the facility did not have a full time IP overseeing infection control practices for all the residents in the facility. Findings: During an interview with the Licensed Nurse (LN) 36 on 2/27/23, LN 36 she was the current IP. A concurrent interview and record review of IP requirements on 2/27/23 was conducted with the Administrator (ADM). The ADM stated Licensed Nurse (LN) 36 did not have the required IP training and certificate. The ADM stated the contracted Interim Director of Nursing (IDON1) was the current IP for the facility. In addition, the ADM stated the Director of Staff Development (DSD) did not have the Infection Control Certificate required for the position. During a concurrent interview and observation on 2/27/23 at 5:35 P.M., the IP was observed with a medication cart in the facility resident hallway. The IP stated he worked part time…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to perform an interdisciplinary team (IDT, staff from different department who coordinates the residents care), assessment, and obtain a physician order for one of 39 residents (Resident 25) when multiple prescribed topical creams were found in a blue container on top of resident's bedside table. This failure had the potential for unsafe and improper administration of the topical cream medications. Findings: Review of Resident 25's admission Record indicated, diagnoses including hypertension (increase in blood pressure), Parkinson's disease (disease marked by tremor, muscle rigidity). On 2/27/23 at 12:12 P.M., an observation in Resident 25's room and concurrent interview with the resident, an opened blue container was placed on the resident's bedside table. Inside the blue container were tubes of Clobatesol gel (skin treatment for psoriasis) hydrocortisone cream (medication to treat itching redness of the skin). Resident 25 applied Clobatesol gel on his face. Resident 25 stated he applied the medication as often…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to address resident's needs and preferences for two of 12 sampled residents (345, 549) when: 1. Resident 549's call light was not within reach. 2. Resident 345's preferred time for administration of her medications were not honored as requested. These failures had the potential for resident's needs not being met. In addition, failure to honor the preferred time of medication administration resulted to Resident 345's refusals of medications and feelings of frustration and low self-worth. Findings: 1. On 3/2/23 at 9:32 A.M., an observation and interview was conducted with Resident 549 in her room. Resident 549 was hitting her table and stated she cannot find her call light to call for help. The call light was on the floor far from her reach. On 3/2/23 at 9:33 A.M., a concurrent observation of the call light inside Resident 549's room and interview with the assistant director of nursing (ADON) was conducted. The ADON acknowledged and stated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to inform a resident's representative of a significant change in physical status for one of one resident (20) reviewed for hospitalization. This failure deprived resident 20's representative of the right of being informed of resident 20's change in physical condition. Findings: A review of resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with multiple diagnoses including paraplegia (inability to voluntarily move the lower half of the body.) The admission Record listed Emergency Contact #1 and Responsible Party as the resident's wife. Resident 20 was transferred to the hospital on [DATE] due to syncope (fainting) and collapse. On 3/6/23 at 9:08 A.M., a review of resident 20's SNF (skilled nursing facility) to Hospital Transfer Form (a form that provides information regarding a resident's clinical status/medical condition), dated 12/27/22 indicated, resident 20's wife was notified of the transfer but was not made…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide a written bed hold notice to the resident's RP (responsible party - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of one resident (20) reviewed for hospitalization. This failure had the potential to result in Resident 20's RP being unaware of Resident 20's return to the facility after hospitalization. Findings: A review of resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included paraplegia (inability to voluntarily move the lower half of the body.) The admission Record listed the resident's wife as the RP. Resident 20 was transferred to the hospital on [DATE] due to syncope (fainting) and collapse. On 3/6/23 at 10:39 A.M., an interview was conducted with the HRD (Human Resources Director.) The HRD stated residents were provided a notification with the daily rates for private and semi-private rooms upon…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to conduct a comprehensive assessments for one of 12 residents (9) reviewed for resident's assessments with a significant change in condition. This failure had the potential to affect the provision of care and treatment/services to be provided to Resident 9. Findings: Resident 9 was re-admitted to the facility on [DATE] with diagnoses which included Pneumonia, Peripheral Neuropathy and Congestive Heart Failure according to the physician's progress notes dated 2/24/23. On 3/1/23 at 8:22 A.M., an observation of Resident 9 was conducted. Resident 9 was in bed with eyes closed. The room had an odorous smell of urine. On 3/1/23 at 8:24 A.M., an interview was conducted with Resident 9. Resident 9 stated he did not have the same control of his bowel and bladder. Resident 9 stated when he had to have a bowel movement, he now needed staff to come right away, otherwise he would lose control. Resident 9 also stated he can walk slowly with his walker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS - a screening and an assessment tool) assessment was accurately coded for one of one resident (19) reviewed for MDS accuracy. This failure had the potential to affect the care and services to be provided for Resident 19. Findings: Resident 19 was admitted to the facility on [DATE] with the diagnosis of Hepatobiliary Cancer (a group of malignancies (abnormal cells divide without control and invade nearby tissues) that includes liver, intra and extra hepatic biliary tracts, and the gall bladder) with Hospice care (care provided when there is no active or curative treatment) according to the physician's progress notes dated 1/12/23. On 2/27/23 at 4:15 P.M., an observation of Resident 19 was conducted. Resident 19 was lying flat in bed with lunch tray at bedside. Resident 19 stated he did not like what was served today, 2/27/23 and had asked for something else. Resident's fingernails were long with blackish debris. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure a baseline care plan was developed and communicated to residents/residents representatives for three of 20 residents (44, 9, 19) reviewed for base-line care plan when: 1. Resident 44 did not have a completed baseline care plan created within 48 hours of admission. 2. Residents 44, 9 and 19 were not provided a written summary of their baseline care plans. As a result of this deficient practice, there was potential for lack of continuity of care and communication among nursing staff. This deficient practice also denied residents and their representatives the opportunity to participate in their care planning process. Findings: 1. A review of resident 44's admission Record indicated the resident was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy (damage or disease that effects the brain), pneumonia (infection of the lungs) and urinary tract infection. On 3/6/23 at 3:55 P.M., an interview and record review was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure care plans were revised/updated for 2 of 12 residents reviewed for care plans. (Resident 9 and Resident 19). This failure had the potential for residents not to receive the care needed to meet their individualized needs for safety, the potential for delayed care, miscommunication among caregivers, and decreased psychosocial well-being. Findings: 1. Resident 9 was re-admitted to the facility on [DATE] with diagnoses of Pneumonia (infection affecting the lungs), Peripheral Neuropathy (weakness, numbness and pain, usually in the hands and feet), and Congestive Heart Failure (a serious condition in which the heart doesn't pump blood as efficiently as it should) according to the physician's progress notes dated 2/24/23. During an observation on 2/27/23, at 9:45 A.M., Resident 9's door was closed. Resident 9 had a visitor and requested for surveyor to return at another time. During an observation on 2/28/23, at 3:54 P.M., Resident 9 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care to maintain good grooming and personal hygiene for 2 of 2 residents sampled for ADL care. (Resident 19 and 350). This failure resulted in Resident 19 having long and dirty fingernails and Resident 350 did not have a shower as scheduled. Findings: 1. Resident 19 was admitted to the facility on [DATE], with the diagnosis of Hepatobiliary Cancer (having to do with the liver, bile ducts, and/or gallbladder) with Hospice care according to the physician's progress notes dated 1/12/23. A joint observation and interview of Resident 19 was conducted with LN 34 on 3/6/23, at 4:30 P.M. Resident 19 was in bed reading the newspaper. Resident 19 was observed with long fingernails with black debris under the nails. LN 34 removed Resident 19's socks and stated Resident 19 also had long toenails. Resident 19 stated he would like his fingernails and toenails trimmed. During an interview with the Interim DON 2 (IDON 2) on 3/8/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide care and services for two of two residents (Resident 549 and Resident 10) when the residents' skin condition was not monitored. This failure resulted in progression of dermatitis (inflammation of the skin) and had the potential to cause further skin breakdown. Findings: 1. Review of Resident 549's clinical record dated 2/21/23 indicated diagnoses of difficulty in walking, need for assistance with personal care, muscle weakness. Review of Resident 549's Minimum Data Set (MDS, a standardized assessment tool), dated 2/24/23, indicated her cognition was intact. The MDS also indicated Resident had urine and bowel incontinent (inability to control urine and bowel movement). On 2/27/23 at 11:58 A.M., a concurrent observation and interview of Resident 549 was conducted. Resident 549 was observed laying in bed grimacing and stated her buttocks was stinging. Resident 549 stated she had soiled her incontinence briefs for, Five hours. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide appropriate interventions to prevent pressure ulcer for one of two sampled residents (Resident 13 ) when Resident 13's heels were not floated while in bed. This failure had the potential to cause or worsen pressure ulcers. Findings: Review of Resident 13's admission diagnoses included, muscle weakness, and need for assistance with personal care. Review of Resident 13's Braden score (Assessment tool to identify pressure sore risk) dated 2/1/23 indicated Resident 13 was, Moderate risk. During an observation on 2/28/23 at 4:16 P.M., Resident 13's heels were not floated while in bed. During a follow up observation and interview with certified nursing assistant (CNA) 15 on 2/28/23 at 5:51 P.M., Resident 13's heels were not floated in bed and heel protectors (padded device used to prevent, manage, treat pressure ulcers) were inside Resident 13's cabinet. CNA 15 acknowledged the observation and stated she was not aware that Resident 13's heels should be floated. During a concurrent observation and interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide a timely bowel and bladder incontinence (inability to control urine and bowel movement) care for one of two sampled residents (Resident 549). This failure had the potential to cause discomfort and skin impairment to all residents. Findings: A review of Resident 549's clinical record dated 2/21/2 indicated diagnoses of difficulty in walking, need for assistance with personal care, and muscle weakness. Review of Resident 549's Minimum Data Set (MDS, a standardized assessment tool), dated 2/24/23, indicated Resident 549's cognition was intact. In addition, the MDS also indicated Resident 549 was urine and bowel incontinent. During a concurrent observation and interview of Resident 549 on 2/27/23 at 11:58 A.M., Resident 549 was grimacing in bed. Resident 549 stated her buttocks were stinging then stated she was wet and soiled in for, Five hours. During an observation with certified nursing assistant (CNA 11) on 2/27/23 at 12:05 P.M., inside Resident 549's room. Resident 549's incontinence brief was soaked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 25) when the incorrect tube feeding formula (delivery of a nutritionally complete feed, containing protein, carbohydrates, fat, water, minerals and vitamins directly into the stomach). was given to there resident. As a result, the resident had the potential to not receive a nutritionally complete diet which could lead to other health complications. Findings: Review of Resident 25's clinical record indicated diagnoses of dysphasia (difficulty swallowing foods or liquids), dementia (loss of memory, language, problem solving abilities). During a concurrent observation and interview with licensed nurse (LN 35) on 2/28/23 at 4:47 P.M., in Resident 25's room, an enteral feeding formula, Novasource renal bag, (brand name, liquid food product that is specially formulated to meet the needs of people with kidney disease) was observed infusing through Resident 25's enteral feeding pump (machine used to continuously deliver nutrition to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the physician supervised and managed the care of one of one residents (Resident 19) who was reviewed for weight loss. This failure had the potential for Resident 19's quality of life to be affected. Findings: During an observation on 2/27/23, at 4:15 p.m., Resident 19 was lying flat in bed with lunch tray at bedside. Lunch tray had uneaten, overcooked cabbage, small amount of mash potatoes and a small amount of meat eaten by Resident 19. Resident 19 stated he did not like what was served and had asked for something else. Resident 19 stated he did not know why he did not get an alternate. Resident 19 stated he did not know if he was losing weight. During an interview on 3/6/23, at 10:31 a.m. with CNA 1, CNA 1 stated Resident 19 required set up for meal and ate 50% - 100% of meals. CNA 1 stated Resident 19 was able to use call light for assistance. During a review of Resident 19's weight in the electronic medical record, the weight record indicated, 11/20/22 122.8 lb, 11/27/22 123.4 lb, 12/4/22 119.2 lb,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Medication Regimen Review (MRR) recommendations were communicated with the physician for 39 residents. In addition, the facility failed to keep pharmacy records of medication recommendation review. As a result, pharmacy medication recommendations were not acted upon, which could affect the medication regimen for all the residents in the facility. Findings: During an interview with the facility's Pharmacy Consultant (PC) on 3/7/23 at 12:42 P.M., the PC stated a full year of MRR reports were sent to the Interim DON last week. The PC stated it was difficult to track if facility was following up on recommendations, and there were no paper trails to evaluate follow up. The PC stated the facility had short term residents, and on the next visit, those residents were already discharged . The PC stated the facility did not send any follow up recommendations to the physician. The Interim DON (IDON 2) was interviewed on 3/8/23 at 4:01 P.M. The IDON 2 stated the MRRs were missing and therefore were not reviewed by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for eleven sampled residents (Residents 28, 556, 19, 553, 551, 547, 14, 554, 551, 1) and a stock bottle of over-the-counter medication when: 1. In 60s hall medication cart, a calcitonin (medication for osteoporosis) nasal spray for Resident 553 was observed laying on side not upright and did not have a use-by date and appropriate patient identifier labels, two opened latanoprost bottles for Resident 547 and an opened latanoprost bottle for Resident 14 did not have use-by date labels, an unopened latanoprost bottle for Resident 554 was being inappropriately stored with no use-by date label, a facility stock bottle of Vitamin A 3000 mcg (microgram- unit of measure) bottle was found to be expired with an expiration date of 12/22, two salmeterol/fluticasone 500/50 diskus…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.